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Review
. 2025 Jul 30:10:100357.
doi: 10.1016/j.jhlto.2025.100357. eCollection 2025 Nov.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: Technical challenges and controversies

Tom Verbelen  1 , Elie Fadel  2 , Christoph B Wiedenroth  3 , David P Jenkins  4 , Michael M Madani  5
Affiliations
Review

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: Technical challenges and controversies

Tom Verbelen et al. JHLT Open. .

Abstract

Chronic thromboembolic pulmonary hypertension requires referral to an expert center for final diagnosis and assessment of treatment possibilities by a multidisciplinary team. Pulmonary endarterectomy is the only potentially curative therapy and therefore remains the treatment of choice. However, many practices and minor technical aspects of this procedure may still provoke controversy. Based on the most recent literature and the author's own experiences and opinions, and in lack of clear guidelines, this review discusses the rationale for blood management strategies; practices during deep hypothermic circulatory arrest; concomitant surgical procedures; pulmonary endarterectomy in specific patient populations, in redo setting and for other diseases; the role of balloon pulmonary angioplasty and of minimal access techniques; and the required surgical expertise. Well-founded recommendations can only be made for a few of them.

Keywords: chronic thromboembolic pulmonary hypertension (CTEPH); deep hypothermic circulatory arrest (DHCA); multimodality treatment; pulmonary endarterectomy (PEA); surgical expertise.

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Conflict of interest statement

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Tom Verbelen reports a relationship with Janssen-Cilag NV, a Johnson & Johnson company that includes: speaking and lecture fees. Christophe Wiedenroth reports a relationship with Johnson & Johnson that includes: consulting or advisory and speaking and lecture fees. Christophe Wiedenroth reports a relationship with OrphaCare that includes: consulting or advisory. Christophe Wiedenroth reports a relationship with MSD that includes: board membership, consulting or advisory, and speaking and lecture fees. Christophe Wiedenroth reports a relationship with AOP-Health that includes: speaking and lecture fees. Christophe Wiedenroth reports a relationship with Bayer that includes: speaking and lecture fees. Christophe Wiedenroth reports a relationship with Inari that includes: speaking and lecture fees. Christophe Wiedenroth reports a relationship with Pfizer that includes: speaking and lecture fees. David Jenkins reports a relationship with Janssen, a Johnson & Johnson company that includes: consulting or advisory and speaking and lecture fees. Michael Madani reports a relationship with Actelion that includes: consulting or advisory. Michael Madani reports a relationship with MSD that includes: consulting or advisory. co-author is member of the executive board of the International CTEPH Association (ICA) - E.F., C. W., D.J., and M.M. co-author is member of the scientific council of the World Symposium on Pulmonary Hypertension (WSPH) and co-chair of CTEPH task force - D.J. co-author is adjudication member of Maciteph and SELECT RCT - D.J. co-author receives royalties from Wexler Surgical - M.M. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Figure 1
Figure 1
Exposure of right (A) and left (B) pulmonary arteries by the inverted-T upper hemisternotomy.
Figure 2
Figure 2
Creation of dissection plan between intima and media in the right main pulmonary artery (A) and resected pulmonary endarterectomy specimens (B).
Figure 3
Figure 3
Sagittal (left) and coronal (right) computed tomography scan images showing hypertrophic bronchial collateral circulation in a chronic thromboembolic pulmonary hypertension patient.
Figure 4
Figure 4
Pulmonary angiography (right) showing complete right sided obstruction of the pulmonary artery with exception of an upper lobe branch. The resected endarterectomy specimen is shown on the left.
Figure 5
Figure 5
Bilateral pulmonary artery sarcoma successfully resected by pulmonary endarterectomy.
Figure 6
Figure 6
Restricted cubic spline analysis to express the relation between annual case volume of pulmonary endarterectomies of 51 centers (52 unique cohorts) and early mortality. Application of the elbow-method to this curve determines the case load that may define a high-volume center. The size of the dots corresponds to the variance of the data. If the variance is small (i.e., there is a high degree of certainty), dots are large, and relatively more weight is assigned to these findings.
See this image and copyright information in PMC

References

    1. Luijten D., Talerico R., Barco S., et al. Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: an updated systematic review and meta-analysis. Eur Respir J. 2023;62 doi: 10.1183/13993003.00449-2023. - DOI - PubMed
    1. Simonneau G., Dorfmüller P., Guignabert C., Mercier O., Humbert M. Chronic thromboembolic pulmonary hypertension: the magic of pathophysiology. Ann Cardiothorac Surg. 2022;11:106–119. doi: 10.21037/acs-2021-pte-10. - DOI - PMC - PubMed
    1. Humbert M., Kovacs G., Hoeper M.M., et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2023;61 doi: 10.1183/13993003.00879-2022. - DOI - PubMed
    1. Madani M., Mayer E., Fadel E., Jenkins D.P. Pulmonary endarterectomy. Patient selection, technical challenges, and outcomes. Ann Am Thorac Soc. 2016;13:S240–S247. doi: 10.1513/AnnalsATS.201601-014AS. - DOI - PubMed
    1. Durrington C., Hurdman J.A., Elliot C.A., et al. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J. 2024;63 doi: 10.1183/13993003.00846-2023. - DOI - PMC - PubMed

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